Eligibility

• You must be receiving unemployment insurance benefits from Massachusetts;
• Your unemployment benefits must be based (at least in part) on earnings from a Massachusetts employer;
• You must be a Massachusetts resident and
• You must also meet income eligibility guidelines. Your total family income for six months prior to the date you apply for the Medical Security Program coverage plus your projected income for the next six months is required to be less than 400% FPG.

Coverage Options
MSP provides two options - Premium Assistance Plan and Direct Coverage Plan.

Under the Premium Assistance Plan, those eligible will receive subsidies for their COBRA premium of up to 80%. If a claimant is eligible for COBRA coverage, or some other health insurance continuation option, the claimant must take the premium assistance option, unless the claimant can claim a hardship, in which case the claimant would be eligible for the direct coverage option. 

Under Direct Coverage those who do not have the option of continuing a health plan, those who have income at or less than 150% FPG and those who've been granted a hardship waiver, may be eligible. They would be enrolled in a Health Maintenance Organization package that includes office visits and screenings, wellness visits for infants and children, hospital care, and treatment for mental health and substance abuse, and prescription drug coverage. There are some co-payments required and you must choose a primary care physician (PCP).

Regulations.

Changes as of January 1, 2012 - "Network Health Extend" new Direct Coverage Plan

Medical Security Program Direct Coverage Switches to Non-Partners Contracted Plan

The state’s Medical Security Program (MSP) is Massachusetts’ health coverage for income-eligible Unemployment Compensation recipients. Those who have MSP Direct Coverage as of January 1, 2012, will automatically be transferred from Blue Cross Blue Shield to Network Health, the new MSP Direct Coverage health insurance provider. This product is called Network Health Extend. Partners Healthcare sites, with the exception of the Island Hospitals, are not contracted with Network Health Extend.

About 23,000 individuals statewide are currently enrolled in MSP Direct Coverage. We do not know how many of these individuals come to our sites for care. Unfortunately, we have no way to identify our patients who may be on this plan ahead of time.

Patients who are transferred to Network Health Extend will no longer be able to come to us for primary or specialty care. They must call Network Health at 1-888-257-1985 for help finding new doctors.

There are some exceptions, but they require that the provider first get a Prior Authorization (PA) from Network Health. Exceptions:

• Primary care patients have a 30 day grace period, so they may see their PCPs through Jan 30.
• Patients who are pregnant and in their second or third trimester may continue in care with us through their first postpartum visit.
• Patients who are terminally ill can continue their care with us.
• Patients who have PA on file may receive the authorized care, but they need to get a new PA from Network Health.
• Patients who are undergoing current or ongoing treatment (such as dialysis, home health, chemo or radiation, inpatient level of care at a hospital or facility) may continue to see their providers until the end of their treatment or for 90 days, whichever comes first.

Providers should follow the instructions for obtaining a PA at www.network-health.org under the provider section.

Children on this plan may be eligible for MassHealth and you may direct families with children to a patient financial counselor for assistance.

Handouts:

• For Patients (English)
  • For Patients (Spanish)
• For Staff

• Plan Changes

  New cost sharing model – The new plan will have no deductible and lower co-payments than your current coverage. You may be required to pay a weekly premium, however, based on your family income and size of your family. Weekly premium costs will range between $0 and $27 per covered individual.  Families with income less than 150% of the federal poverty level, children under 19, disabled individuals and pregnant women are exempt from premiums.

  More plan information: http://www.network-health.org/msp/

***

Cost Containment/Benefit Reductions as of January 1, 2010:

Rising unemployment and federal unemployment assistance extensions have put a strain on this program, and the state has enacted several changes that are intended to contain costs. Those low income members receiving "Direct Coverage" will be enrolled in a Blue Cross plan called Network Blue Options v3 Deductible. More information.

Programmatic changes:

• Co-pays and deductibles will be tiered* depending on provider and hospital, based on quality and cost measures
• Co-pays for primary care visits will move from $15 to $15/25/50 (MGH, BWH, and NSMC are in the most expensive tier)
• Co-pays for specialist visits will increase from $30 to $50
• Co-pay for an emergency room visit will increase from $100 to $150
• Co-pays for prescription drugs will increase from $10/20/35 to $15/30/50
• Co-pays for inpatient/day surgery will change from $250 or $600 depending on the hospital to $150 with varying deductibles, depending on the hospital
• The out of pocket maximum will increase from $2,000 for an individual and $4,000 for a family to $5,000 and $10,000 (includes deductible, co-insurance and co-pays under $100)

*More information on tiering:

• 8% of current enrollees live within 8 miles of 2 doctors at the $15 level, and 100% live within 8 miles of 2 doctors at the $25 level
• There are 39 hospitals statewide in the “enhanced” (cheapest) category; 14 in the “standard” (mid-level) category; and 23 in the “basic” (most expensive) category

Here’s what will stay the same:

• Income eligibility for the program is still to 400% FPG
• Enrollee premiums are still $0

Administrative changes:

• Previously, an individual must be eligible for premium assistance for just one day of a month to receive coverage for that month. Now, one must be eligible for at least 10 days.
• Previously, those under 200% of the federal poverty level were given presumptive hardship waivers (allowing them to get direct coverage instead of paying for COBRA through the Premium Assistance Plan). Now, the presumptive level is 150% FPG. (Anyone else may still apply for a hardship waiver.)